A 40-year old, right hand dominant male presented to the clinic with a long-standing history of right wrist pain. He had sustained a right scaphoid fracture when he was 18 years old in the military, which was treated with cast immobilization. Following the 6-8 weeks of cast immobilization, the patient was instructed to return to regular activities. Since that time, the patient has experienced intermittent wrist pain that, at times, limits his ability to perform normal activities. When the pain exacerbations occur, the patient had avoided using his wrist as much as possible to allow his symptoms to subside. This typically takes about 3 weeks. The patient has had multiple episodes of this yearly, occurring every couple of months. The most difficult activities he reported were wringing out a washcloth, lifting a gallon of milk, and any type of repetitive task.
The patient worked as an accountant; however, he enjoyed remodeling his home, which required significant use of his involved hand with holding and swinging a hammer and using power tools.
On examination, wrist range of motion (ROM) demonstrated 75 degrees of palmer flexion and 75 degrees of dorsiflexion. Forearm supination and pronation were 70 degrees in each direction. Grip on his involved side was 47 pounds, versus 97 pounds on the uninvolved left. Pain with gripping was rated a 4 out of 10 (on a 0-10 pain scale). The pain was localized to the snuff box and scapholunate region, but the Watsons (Scaphoid Shift) test produced minimal pain and no subluxation.
Radiographs, static anterioposterior, lateral, oblique, and navicular views, and dynamic bilateral clenched fist views demonstrated no definitive scaphoid fracture or obvious pathologic lesions. There was some irregularity at the radial aspect of the lunate at the scapholunate interval possibly suggestive of a bony type of lesion at that level. On the clenched fist view, there was some gapping present at the scapholunate interval and a cyst present within the lunate.
An MRI was ordered and demonstrated no frank abnormalities to the radial side of the wrist. The scapholunate ligament appeared to be intact. Following results of the essentially negative MRI, the patient was referred to therapy for strengthening.
On the therapy evaluation, the patient’s joint-specific mobility was assessed with particular attention focused on the mobility of the radial column: scaphoid-on-radius (
Figure 1) and trapezoid-on-scaphoid (
Figure 2). The patient’s history of scaphoid fracture with cast immobilization and lack of follow up therapy may have contributed to the development of joint-specific limitations as a consequence of the cast immobilization.
Figure 1
Figure 2
The clinical reasoning behind addressing the joint specific mobility of the carpals themselves comes from the concept of the wrist being a kinematic chain. With any type of movement of the wrist, there are small motions that occur between the carpals. If movement in one articulation becomes limited (from inflammation, immobilization, etc.), it places increase stress on the surrounding joints. A scaphoid fracture likely produced localized joint-specific limitations at the scaphoid-on-radius and/or the trapezoid-on-scaphoid articulations contributing to pain and abnormal loading patterns with gripping and weight-bearing tasks.
With manual testing, the scaphoid-on-radius articulation demonstrated a moderate limitation and the trapezoid-on-scaphoid articulation moderate to severe limitation. The trapezium-on-scaphoid and capitate-on-scaphoid need not be tested as Moriomoto et al1 has shown that the trapezium, trapezoid, and capitate functionally move as a unit. The patient also demonstrated a capsular pattern of limitation at the carpometacarpal (CMC) articulation.
The patient was seen for a total of five visits. Manual therapy treatment consisted of joint-specific manipulation of the scaphoid on the radius (
Figure 3) and the trapezoid on the scaphoid (
Figure 4) and joint mobilization techniques to restore capsular mobility at the thumb CMC joint. A joint-specific manipulation is a high-velocity, low-amplitude thrust which addresses the small collagen cross linkages that can develop in a joint during a long period of immobilization.
Figure 3
Figure 4
The patient was also issued a Wrist Restore pre-fabricated brace, which maintained contact at the distal pole of the scaphoid to prevent excessive flexion. With application of the Wrist Restore brace, the patient demonstrated an 18# improvement in grip with no complaints of pain. He was instructed to use the Wrist Restore Brace with heavier repetitive activities involving gripping and weight bearing. The patient was also instructed in isometric wrist strengthening and eccentric wrist extensor strengthening with a 10-pound flex bar.
At his final therapy visit, the patient demonstrated grip strength of 102 pounds with no complaints of pain. He reported he could perform all of his activities of daily living, including lifting a gallon of milk and wringing out a washcloth pain-free. He noted occasional pain rating a 1 out of 10 with lifting, but the pain subsided immediately after the activity. The patient appeared very pleased with his status, as he could now return to his home remodeling projects without the 2-3 week interruption of wrist pain that had occurred over the past 10 years.
Manual therapy intervention, utilizing joint-specific manipulation techniques, played a significant role in the recovery of this patient. Over the 6 weeks he was followed, the patient regained 55 pounds of grip strength and was now pain-free with all lifting, twisting, and weight bearing tasks. Manual therapy, delivered by a skilled therapist, can play a critical role in the recovery of patients with non-specific wrist pain following a healed scaphoid fracture.
References:
1. Moritomo H, Viegas SF, Elder K, Nakamura K, DaSilva MF, Patterson RM. The Scaphotrapezio-trapezoidal joint. Part 2: A kinematic study. J Hand Surg 2000; 25A: 911-920.